In episode four of Care Decoded, Dr. Sunil Nihalani sits down with Biodun Kajopaiye (BK), Risk Adjustment and Stars Manager at CareFirst Blue Cross Blue Shield, to break down one of the most consequential shifts in Medicare Advantage: the transition to the CMS-HCC Version 28 model.
If you work in risk adjustment, coding, quality, stars, population health, or provider operations, the move from V24 to V28 isn’t just a model update—it’s a fundamental rewiring of how diagnoses are captured, valued, validated, and paid.
This is the clearest, most clinician-friendly breakdown of V28 you’ll find: what changed, why it changed, who it impacts, and how leaders can stay ahead of what’s coming next.
V28 represents CMS’s shift toward greater clinical specificity and more accurate cost prediction. While V24 included 86 HCCs, V28 expands that to 115 categories while removing nearly 2,000 ICD-10 codes that CMS deemed low-value or clinically irrelevant.
The goal:
Cleaner problem lists, more precise documentation, and risk scores that better reflect real-world cost of care.
CMS recalibrated major conditions—including diabetes, depression, vascular disease, and morbid obesity—while significantly adjusting the weight of pharmacy-based risk (RxHCCs), acknowledging how much medication drives total cost.
BK explains that the biggest shift is specificity and accountability.
Example:
All diabetes categories—no complications, with complications, with acute complications—now carry the same coefficient. Providers no longer gain additional value from documenting the complication type; instead, they must consistently capture the diabetes itself.
Other conditions, like cirrhosis, now carry higher weight—meaning under-documentation can have bigger financial consequences.
Across health plans, early data shows lower RAF scores, not because patients are healthier, but because documentation patterns haven’t caught up to the new model.
Version 28 has amplified the fragile dynamic between health plans and providers.
Providers are dealing with:
More administrative pressure
Higher documentation expectations
Rising scrutiny under RADV
Additional KPIs embedded directly into contracts
Health plans are facing:
Revenue drops tied to RAF declines
RADV exposure across five years of payment
Urgent pressure to clean data, delete unsupported codes, and train networks
Mounting demand to shift from retrospective to prospective risk programs
BK puts it plainly:
If a network doesn’t fully transition to V28, the financial losses are measured in millions.
BK lays out a hidden risk often missed in traditional workflows:
Poor documentation means chronic conditions disappear year-over-year
Third-party coders cannot infer clinical intent
Health plans end up submitting codes that may not be fully supported
Or they miss codes entirely
Both scenarios trigger either revenue loss or audit exposure
The new model, combined with aggressive RADV expansion, means retrospective-only strategies are no longer sustainable.
According to BK and Dr. Nihalani, the future requires:
Better EHR-integrated insights
High-confidence clinical signals
Data flowing seamlessly from specialists to PCPs to the plan
A provider-first design philosophy
Stronger data integrity and fewer duplicates
Real-time gap visibility
Cleaner problem lists
Point-of-care support that adds clarity, not noise
Technology must amplify clinical judgment—not interrupt it.
If there’s one message from BK, it’s this:
Accuracy must come before revenue. If you get accuracy right, revenue will follow.
Leaders who want to stay ahead of V28, V29, future models, or policy shifts should focus on:
Contracting that reinforces documentation and recapture
Education for networks and frontline clinicians
Moving from retrospective to prospective workflows
Building trust in clinical insights
Ensuring CDI programs are continuous, not episodic
Aligning actuary, finance, quality, and RA teams
Prioritizing data cleanliness
Understanding network maturity across KPIs
Complementary payer–provider partnerships
Technology that delivers signal—not noise
BK captured it perfectly:
“Help physicians find the music among the noise.”
BK believes yes.
V28:
Reduces noise
Rewards clinical relevance
Improves cost prediction
Elevates key conditions
Tightens documentation expectations
Prepares the industry for more data-driven models
Builds the foundation for future additions, such as social determinants of health
Change is painful. But it’s also necessary—and V28 is a step toward a more accurate, more sustainable, and more clinically aligned system.
Risk adjustment is no longer a back-office function.
V28 forces providers and plans to collaborate, to clean data, to modernize workflows, and to build a shared operational language grounded in clinical integrity.
As Dr. Nihalani notes, “Taking care of patients is hard enough. We shouldn’t make documentation harder than it needs to be.”
In episode four of Care Decoded, Sunil and BK show exactly what leaders need to understand—and what they need to do next—to succeed in a V28 world.
